Assessing Suicide Risk in Children: Guidelines for Developmentally Appropriate Interviewing

Significance of the Issue: Suicide is a leading cause of death across age groups in the United States.
- According to the National Institute of Mental Health (NIMH, 2003), suicide accounts for approximately 5.8% of deaths in 10-14 year-olds (Gould, Shaffer, & Greenberg, 2003).
- It is the 3rd to 7th leading cause of death among 5-14 year olds (American Association of Suicidology [AAS], 2006).
Prevalence of Suicidal Behavior: Although completed suicide is relatively low, suicidal thoughts and behaviors in children are common.
- AAS (2006) estimates that youth make approximately 100-200 suicide attempts for each completed suicide.
Challenges in Assessment: Many mental health counselors express discomfort in addressing suicide with children, amplified by myths, misconceptions, and lack of awareness (Wise & Spengler, 1997).
- Prevalence is often underestimated due to classification errors and adults' reluctance to believe children can engage in suicidal planning.
Objective of the Article: To review risk factors for childhood suicide, provide methods for assessing suicide risk in children, and guidelines for developmentally appropriate interviewing.

Theoretical Models: Various models help interpret and understand suicide risk factors, emphasizing integration of biological, psychological, and sociological theories (Berman et al., 2006).
Multidimensional Suicide Trajectory Model (Stillion & McDowell, 1996): Guides exploration of common risk factors across developmental stages.

Impulsivity: Higher levels of impulsivity are associated with increased suicide attempts due to spontaneous actions (e.g., running in front of cars).
Sex and Age*
- Similar rates of suicide attempts in prepubescent children but differences emerge after age 10 (Wise & Spengler, 1997).
- The gap grows as age increases; by adolescence, boys complete suicide more often while girls attempt more.

Disturbances in Functioning: Children at risk may experience psychological disturbances or diagnosable mental health disorders (Brent & Kolko, 1990).
- Common symptoms include depression, anxiety, aggression, and impulsivity, often leading to problems with coping and feelings of hopelessness.

Immature Understanding of Death: Young children may not fully grasp the implications of their actions related to life and death (Stillion & McDowell, 1996).
Rational Thought Loss: Associated with auditory/visual hallucinations, rational loss, and the impact of substances.

Family Dynamics: High risk associated with early loss, parental conflict, abuse, parental mental health issues, and isolation from peers (Stillion & McDowell, 1996).
- Family dysfunction hampers the provision of emotional support and can bolster feelings of distress in the child.

Stressors: Events perceived as significant by children, such as family crises, health problems, and exposure to suicide, can contribute to suicidal ideation.
- Prior suicidal thoughts and attempts are strong indicators of future risk (Gould et al., 2003).

Counselor Preparation: Mental health counselors should address personal discomforts and fears regarding suicide assessments (Shea, 1999).
- Being adequately prepared may alleviate discomfort and improve the assessment process.
Understanding the Child's Development Level: Counselors need to adapt questions and assessment tools to the child's developmental stage to ensure effective communication.

Purpose of the Interview: To alternate between problem-solving and ecological structuring while assessing the need for further services.
Crisis Intervention Model (Roberts & Yeager, 2005): Consists of 7 stages including planning, establishing rapport, identifying problems, dealing with feelings, generating alternatives, and establishing a follow-up plan.
- 1. Planning and Conducting Assessment: Engage the child and caregivers to build rapport, clarify the purpose of the interview, and ensure a non-threatening environment.
- 2. Establish Rapport Quickly: Initiate small talk to convey interest; inform the child they are safe and not in trouble.
- 3. Identifying Major Problems: Utilize open-ended prompts for children to narrate relevant events or situations that might have led to their feelings (Wilson & Powell, 2001).
- 4. Address Contemplation of Suicide: Carefully probe suicidal ideation while remaining sensitive to the child's comfort level through gentle assumptions (e.g. phrases like, "Many kids feel this way when…" ) to normalize their feelings.

Ethical Responsibility: Mental health counselors play a vital role in identifying and intervening in cases of childhood suicide.
Continued Education: Counselors must educate themselves on risk factors and intervention strategies, engage in consultations and supervision, and allow time for debriefing challenging sessions for optimal practice.

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